Mechanisms of exposure and response prevention in obsessive-compulsive disorder: effects of habituation and expectancy violation on short-term outcome in cognitive behavioral therapy

Abstract

Background Exposure and response prevention is effective and recommended as the first choice for treating obsessive-compulsive disorders (OCD). Its mechanisms of action are rarely studied, but two major theories make distinct assumptions: while the emotional processing theory assumes that treatment effects are associated with habituation within and between exposure sessions, the inhibitory learning approach highlights the acquisition of additional associations, implying alternative mechanisms like expectancy violation. The present study aimed to investigate whether process variables derived from both theories predict short-term outcome. Method In a university outpatient unit, 110 patients (63 female) with OCD received manual-based cognitive-behavioral therapy with high standardization of the first two exposure sessions. Specifically, therapists repeated the first exposure session identically and assessed subjective units of distress as well as expectancy ratings in the course of exposure sessions. Based on these data, individual scores for habituation and distress-related expectancy violation were calculated and used for prediction of both percentage change on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and remission status after 20 therapy sessions. Results In a multiple regression model for percentage change, within-session habituation during the first exposure was a significant predictor, while in a logistic regression predicting remission status, distress-related expectancy violation during the first exposure revealed significance. A path model further supported these findings. Conclusions The results represent first evidence for distress-related expectancy violation and confirm preliminary findings for habituation, suggesting that both processes contribute to treatment benefits of exposure in OCD, and both mechanisms appear to be independent.

Inhibitory Learning versus Habituation in an Experimental Exposure Intervention for People With Heightened Health Anxiety: Increase of Distress Tolerance as a Joint Mechanism of Change?

“…Fifth, the recruitment process was stopped prematurely due to the onset of the COVID-19 pandemic and the statistical power, particularly for the detection of between-group effects, was therefore compromised. Sixth, the study misses a longterm assessment of effects of both interventions; in line with findings of Brown et al (2017) and Elsner et al (2022), a superiority of an IL-based exposure intervention might only be seen in relation to long-term outcomes (e.g., return of fear).…”

“…It could be important to develop fears that a priori are assessed as probable and still threatening. Furthermore, previous results suggested that positive effects of an IL-based exposure/extinction training, which aims at mismatching expectancies, are rather seen over a long-term perspective (i.e., after further therapy sessions, after one week in an extinction retention testing) (Brown et al, 2017; Elsner et al, 2022). Thus, we cannot exclude that effects of the IL-based intervention in the present study only would have become evident at a later point of time (e.g., in tests on return of fear or in a later assessment).…”

Intolerance of uncertainty as a cognitive vulnerability for obsessive-compulsive disorder: A qualitative review.

“…Though cognitive approaches to reducing IU may be useful, behavioral changes may be equally effective; belief change is a mechanism of effective exposure interventions, which target behavioral change (Knowles & Tolin, 2022). For instance, distress-related expectancy violation during exposure predicted OCD remission in a recent study (Elsner et al, 2022); similar violation in expectancies in one's ability to tolerate uncertainty may also mediate OCD symptom reduction during exposure. Understanding how established OCD risk factors (i.e., obsessive beliefs) fit into the nomological network of IU will be an important next step in understanding the broader construct of IU and the extent to which its association with OCD symptoms is distinct or a function of other related constructs, as well as inform OCD treatment.…”

Does prediction error during exposure relate to clinical outcomes in cognitive behavior therapy for social anxiety disorder? A study protocol

“…Only a handful of studies to date have explored whether prediction error during exposure relates to treatment outcomes. This hypothesis has been tested in exposure-based treatment for obsessive compulsive disorder (41)(42)(43), panic disorder (44), and post-traumatic stress disorder (45). Results have been mixed with some studies finding an association between prediction error during exposure and treatment outcomes (41,43), while other studies have found no such effects (42,45).…”

“…This hypothesis has been tested in exposure-based treatment for obsessive compulsive disorder (41)(42)(43), panic disorder (44), and post-traumatic stress disorder (45). Results have been mixed with some studies finding an association between prediction error during exposure and treatment outcomes (41,43), while other studies have found no such effects (42,45). These mixed results may be due to three limitations in the research-broadly described as conceptual, statistical, and methodological issues that are summarized below.…”